While I was on my four-state trip out West, a small item crossed my news feed. Politico picked it up from the New York Times story about the WHO meeting and the US’s bullying of Ecuador. The US representatives were trying to dilute the World Health Organization’s support of breastfeeding. They were encouraged by business interests that sell infant formula and substitutes for mother’s milk. The full story is below.
When I raised this US behavior with audiences, they didn’t know about it. They were mostly business, markets, economic types. Most of them missed Trump’s tweet about the WHO and NY Times.
They were mostly appalled by US behavior once the full story was revealed. Note that they generally do not trust most media, whether Fox or CNN. But they do respect careful research with citations.
So why didn’t they know? Machine learning and algorithms are altering their news flow. Readers who track healthcare and women’s issues knew about it. Certainly those interested in infants and mothers and nursing saw it. But the financial world missed it.
Algorithms designed to keep you reading determine your news flow in many sources and give you what logic (mathematics) determines interests you. So the 200 or so people I met with, mostly men, mostly from Western states, and mostly Republican-leaning, learned a fact set that they found to be new information and deeply troubling.
Delving into this story shaped a resolution I invite all to embrace: A mother who seeks to breastfeed her infant is to be supported and assisted. Commercial interests that seek to put their financial interest ahead of breastfeeding by mothers are committing an abhorrent act.
Here are the details of the story:
The World Health Organization’s 71st World Health Assembly, held May 21–26 in Geneva, was attended by delegations from 194 WHO member countries, who came together to address diverse health-related issues, including child nutrition.
One resolution brought before the assembly, crafted by Ecuador and four other countries, sought to lend support and protection for breastfeeding as a best practice for infants’ nutrition by strengthening WHO’s on-the-ground support for the 1981 “International Code of Marketing of Breast Milk Substitutes.” That 1981 code was aimed at curbing the inappropriate marketing of breast milk substitutes as being equivalent to or better than a mother’s own milk. (See https://www.snopes.com/news/2018/07/09/importance-of-breastfeeding-resolution/.)
The US Centers for Disease Control (CDC) summarizes the 1981 code here:
https://www.cdc.gov/breastfeeding/pdf/strategy9-addressing-marketing-infant-formula.pdf. Among its guidelines for makers of baby formula are no direct advertising, no free samples, no courting healthcare workers with gifts, no product representatives acting as advisers to new mothers, and a stipulation that “All information on artificial feeding, including product labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.” The code in its entirety may be found here: http://www.who.int/nutrition/publications/code_english.pdf.
Why would protecting a mother’s right to information about the superiority of breastfeeding for optimal infant health and nutrition be such a big deal? While both breast milk and breast milk substitutes have the fat, carbohydrates, vitamins, minerals, water, protein, and DHA/ARA that babies need, formula simply lacks the hormones, enzymes, growth factors, and antibodies that offer children a measure of protection from illnesses, parasites, and even allergies. (For more information, see https://www.askdrsears.com/topics/feeding-eating/breastfeeding/why-breast-is-best/comparison-human-milk-and-formula.)
An excellent Quartz article marshaling the longstanding evidence for breastfeeding sums up what is at stake in a key paragraph:
“Cesar Victora, a professor of epidemiology, estimated in 2016 (pdf) that each year, 823,000 deaths in children under five years of age and 20,000 deaths from breast cancer could be prevented by near-universal breastfeeding. Other research estimated the global health costs of not breastfeeding—that is, the amount of money spent caring for children and women with chronic disease and short-term illnesses that might have otherwise been avoided—at $300 billion, or 0.49% of world gross national income.” (https://qz.com/1323572/all-the-science-on-breastfeeding-that-the-us-ignored-by-opposing-a-world-health-resolution/) Numbers don’t get any more compelling than that.
Compliance with the 1981 code, however, is uneven and unassured, even where the code is law, so any progress will save both children’s lives and dollars. First, for formula to be safe, it has to be made with clean water, and some 780 million people worldwide lack reliable access to that vital resource. Second, children fed formula suffer more often from diarrhea and respiratory illnesses than breastfed children do. Third, buying baby formula is considerably more expensive than buying enough extra food to feed a nursing mother so that she can adequately nurse her child. Formula is so expensive, comparatively speaking, that mothers in poverty often can’t buy enough of it and end up feeding less than they should. (See https://www.npr.org/sections/goatsandsoda/2018/07/13/628105632/is-infant-formula-ever-a-good-option-in-poor-countries.)
A joint investigation by The Guardian and Save the Children, conducted in the Philippines, turned up flagrant violations of the 1981 code and aggressive marketing practices by companies peddling baby formula in a country where the question of breast milk vs. formula is more likely to be a matter of life and death than it is in developed countries.
The Guardian profiled, among other mothers, Jessica Icawat, 24, who lives in a poor section of Manila with her two-year-old daughter, Trista. Icawat began feeding her baby Nestlé’s formula Nestogen, which she believed to be as good for Trista as breast milk would have been. The result has been hunger for her and for her daughter, who has now been hospitalized three times for diarrhea and asthma:
“Stick thin, her cheek and collarbones sticking out, Icawat was visibly malnourished, as was Trista, whose swollen stomach stuck out beneath a faded pink Little Mermaid T-shirt. The average cost of Nestogen is 2,000 pesos (£28) a month, but Icawat could afford to spend only 800 pesos….
“‘I didn’t eat just so I could feed the baby,’ she said. ‘There were some days when I didn’t eat anything. And Nestogen is expensive, so I could not always give it to my baby when she was hungry; I only gave her half bottles, four times a day.’”
The Guardian article, which can be read here (https://www.theguardian.com/lifeandstyle/2018/feb/27/formula-milk-companies-target-poor-mothers-breastfeeding), summed up the findings of the investigation:
“Nestlé and three other companies were offering doctors, midwives and local health workers free trips to lavish conferences, meals, tickets to shows and the cinema and even gambling chips, earning their loyalty. This is a clear violation of Philippine law.
“Representatives from Nestlé, Abbott, Mead Johnson and Wyeth (now owned by Nestlé) were described as a constant presence in hospitals in the Philippines, where only 34% of mothers exclusively breastfeed in the first six months. Here, they reportedly hand out ‘infant nutrition’ pamphlets to mothers, which appear to be medical advice but in fact recommend specific formula brands and sometimes have money-off coupons.
“Hospital staff were also found to be recommending specific formula brands in lists of ‘essential purchases’ handed to new mothers. Targeted advertising on Facebook and partnerships with influential ‘mummy bloggers’ means mothers are being exposed to more unregulated formula promotion than ever before.”
The resolution brought before the World Health Assembly in May was specifically designed to help countries end such unethical and often illegal practices. According to the International Code Documentation Centre (ICDC), the resolution “aimed to safeguard 5 critical areas – the Baby-friendly Hospital Initiative (BFHI), implementation and monitoring of Code and relevant WHA resolutions, WHO Guidance on ending inappropriate promotion of foods for infants and young children (the 2016 WHO Guidance), appropriate infant and young child feeding in emergencies, and conflicts of interest in nutrition programmes” (https://www.ibfan-icdc.org/scrutinisng-the-2018-wha-resolution-on-iycf-how-to-salvage/). As Chloe Schama, writing for Vogue, sums up the WHO effort, “It’s about preventing misleading marketing from formula makers seem like the easy option, when breastfeeding may be safer and more beneficial” (https://www.vogue.com/article/breastfeeding-trump).
At the meeting, no one was expecting a resolution that could potentially save the lives of more than 800,000 infants a year to be controversial – at least not until the US delegation opposed it. According to the New York Times report, “American officials sought to water down the resolution by removing language that called on governments to ‘protect, promote and support breast-feeding’ and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children” (https://www.nytimes.com/2018/07/08/health/world-health-breastfeeding-ecuador-trump.html).
The New York Times reported that the American delegation did more than simply oppose the resolution as originally written: “When that failed, they turned to threats, according to diplomats and government officials who took part in the discussions. Ecuador, which had planned to introduce the measure, was the first to find itself in the cross hairs
Threats aside, a revised resolution introduced by Russia and reflecting a compromise would eventually pass. The final version (http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_ACONF4Rev1-en.pdf) kept the general language supporting breastfeeding but removed specifics that would have had key positive impacts for the health of young children globally. For example, the final resolution no longer specifically urges WHO Member States to implement the 2016 WHO guidance on inappropriate promotion of foods for infants and young children. Further, as the ICDC explains, the final version weakens the original resolution’s call for WHO’s active support:
“The original draft requests WHO to provide technical support to Member States, specifically in implementation and monitoring of the International Code and subsequent relevant WHA resolutions, the 2016 WHO Guidance, and BFHI. The revised provision omitted the three important components, and was replaced with a generalised text (OP2.1). There are a number of initiatives led by WHO in recent years to support countries in scaling up protection, promotion, and support of breastfeeding and optimal infant and young child feeding. Some examples are Code monitoring support through NetCode, implementation guidance on BFHI through Ten Steps to Successful Breastfeeding, and the Implementation Manual on the WHO Guidance – all of which work to curb aggressive marketing practices in different ways. Weakening of WHO’s support will hinder the progress on these initiatives, likely resulting in countries facing industry wielding its influence to obstruct or undermine attempts to curtail inappropriate marketing practices. It is necessary to recall the numerous previous resolutions that reinforced WHO’s obligation to provide support on implementing and strengthening these components.” https://www.ibfan-icdc.org/scrutinisng-the-2018-wha-resolution-on-iycf-how-to-salvage/
Following the publication of the New York Times story, Donald Trump weighed in on Twitter, defending the US position:
There was, however, nothing fake about US opposition as reported in the New York Times, and there was nothing fake about the changes made in the final resolution, which were, in fact, designed to protect the marketing activities of companies that produce breast milk substitutes.
The US government does in fact support breastfeeding here in the US. The CDC actively promotes it and tracks breastfeeding rates. US insurers writing new policies are currently required by law to provide breastfeeding counseling, and those who serve in the military have long had the benefit of breastfeeding counselors through Tricare (https://www.tricare.mil/CoveredServices/IsItCovered/BreastfeedingCounseling).
The argument that women shouldn’t be denied access to formula is, of course, reasonable, in that there are some women who, for one reason or another, cannot breastfeed. That number is fewer than 5%. Women would not have, under the original resolution, been denied access to formula. They would, however, have been informed of the superior benefits of breast milk and not misled by baby formula advertising that positions formula as an advantageous choice.
Trump’s argument that “Many women need this option because of malnutrition and poverty” simply doesn’t hold (potentially contaminated) water. Because formula is the more expensive option, formula is not the most economical choice for mothers in poverty; and when mothers who can’t afford enough of it and consequently feed less than babies need or water the formula down, malnutrition results.
Still, the administration defended the US position to Snopes investigators, who followed up on the New York Times story: “‘The resolution as originally drafted placed unnecessary hurdles for mothers seeking to provide nutrition to their children,’ an H.H.S. spokesman said in an email. ‘We recognize not all women are able to breast-feed for a variety of reasons. These women should have the choice and access to alternatives for the health of their babies, and not be stigmatized for the ways in which they are able to do so.’ The spokesman asked to remain anonymous in order to speak more freely.” (https://www.snopes.com/news/2018/07/09/importance-of-breastfeeding-resolution/)
The US’s position at the World Health Assembly fundamentally represented corporate interests over optimal infant health and hundreds of thousands of lives. As the New York Times reported in its July 8 piece, “The $70 billion [baby formula] industry, which is dominated by a handful of American and European companies, has seen sales flatten in wealthy countries in recent years, as more women embrace breast-feeding. Over all, global sales are expected to rise by 4 percent in 2018, according to Euromonitor, with most of that growth occurring in developing nations.” Clearly, however, aggressive marketing that promotes a suboptimal form of infant nutrition to mothers who may not be able to afford that expensive product is not an ethical proposition. And it is not as if those mothers can change their minds later. The fact that a market can potentially be expanded does not mean that it should be when harm results.
There you have it. This conclusion bears repeating: A mother who seeks to breastfeed her infant is to be supported and assisted. Commercial interests that seek to put their financial interest ahead of breastfeeding by mothers are committing an abhorrent act.
David R. Kotok
Chairman & Chief Investment Officer
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